Claimant's Statement for Death Claim - RA



|This page to be kept by claimant |

|BENEFITS PAYABLE ON THE DEATH OF A MEMBER FROM A |

|LIFESTYLE RETIREMENT ANNUITY FUND, LIFESTYLE PRESERVER PENSION FUND |

|OR LIFESTYLE PRESERVER PROVIDENT FUND |

| |

|Each of the above-mentioned funds is a separately registered retirement fund, managed by a board of trustees (“the trustees”). For purposes of the |

|completion of this form, references to the funds are simply “the Fund”. |

|Allocation and distribution of the benefits payable by the Fund on the death of the member is governed by Section 37C of the Pension Funds Act, 1956 as |

|amended (“the Act”). In terms of this section, benefits are payable to the dependants of the deceased member (including the deceased member's immediate |

|family and anyone who was actually dependent on the deceased member prior to their death) as well as to beneficiaries nominated in writing by the deceased |

|member prior to his/her death. |

| |

|Wide powers for trustees |

|Section 37C of the Act confers wide powers and responsibility upon the trustees to decide who will benefit and the extent of the benefit. In all cases, the |

|trustees are responsible for the distribution and allocation of benefits in the proportions they deem fair and equitable to each dependant or nominated |

|beneficiary and whether the benefit should be paid in the form of a lump sum or a pension. |

| |

|Code of good practice |

|The trustees of the Fund will apply the following code of practice when distributing benefits to beneficiaries and/or dependants: |

| |

|The trustees will make every effort to identify both legal and factual dependants of the deceased member. Specifically, the trustees will rely on: |

|Information stated on the Claimant Statement form that is completed by each claimant; |

|Information stated by the deceased member before his/her death on the Identification of Dependants and Nomination of Beneficiary form; |

|Any statements made by the deceased member's family; |

|Any other information that can be obtained. |

| |

|The trustees will consider any persons nominated in writing by the deceased member before his/her death. |

| |

|Based on the information gathered in terms of items 1 and 2 above, the trustees will determine the distribution of the after-tax approved proceeds in terms |

|of Section 37C of the Act. |

| |

|Persons considered to be dependants |

|Dependants fall into several categories: |

|Legal dependants such as an ex-spouse with a maintenance order; |

|Factual dependants, persons dependent upon the deceased member for financial support, such as a spouse and children. |

|Persons who would have become dependants but for the deceased member’s death, such as an unborn child. |

| |

|In summary, all the deceased member’s dependants, irrespective of whether they were actually nominated by the deceased member, will be considered for |

|inclusion alongside any other persons nominated by the deceased member and irrespective of whether such persons are dependants. |

| |

|The trustees are empowered to delay payment of any benefits for up to 12 months in order to trace dependants and to be able to make a considered |

|determination. |

| |

|Payments to non-dependent nominees |

|In cases where there are only non-dependent persons nominated, the trustees will generally make payment in accordance with the wishes expressed by the |

|deceased member in the beneficiary nomination form. However, the trustees first have to satisfy any possible degree of insolvency in the deceased member’s |

|estate before making any payment to non-dependent nominees. |

| |

|No dependants or nominees |

|If there are neither dependants nor nominees then the trustees will make payment to the deceased member’s estate. |

| |

|Bequests in wills and testamentary trusts |

|It should be noted that any expression of wish in respect of the benefits payable from the Fund contained in the deceased member’s will have no binding |

|effect on the trustees, although they will have regard to the will in their efforts to establish the deceased member’s dependants. In particular, the |

|trustees will not distribute benefits to any testamentary trust formulated in terms of the deceased member’s will. |

|CLAIMANT’S STATEMENT FOR DEATH CLAIM |

|LIFESTYLE RETIREMENT ANNUITY FUND, LIFESTYLE PRESERVER PENSION FUND OR |

|LIFESTYLE PRESERVER PROVIDENT FUND |

| |

|We are required to share, collect and process your Personal Information (PI) in order to process any claim. Your PI is collected and processed by our staff, |

|representatives or sub-contractors and we make every effort to protect and secure your PI.  You are entitled at any time to request access to the information |

|Liberty has collected, processed and shared. |

| |

|Please send the completed form to Liberty by: |

|Email: opsclaims@liberty.co.za |Fax: (011) 408 2005 |Post: PO Box 10499, Johannesburg, 2000 |

| |

|Standard requirements – please attach copies of the following documents |

| |

| |Death certificate. |

| |Beneficiary’s/dependant’s ID document or copy of the back and front of ID smart card. |

| |Birth certificate if beneficiary is a minor, passport if not a S.A. citizen. |

| |Proof of each beneficiary’s and dependant’s bank details (original bank statement or cancelled cheque). |

| |Marriage certificate (if applicable). |

| |Last will and testament. |

| | |

| |Letters of executorship. |

| |Divorce decree (if applicable). |

| |Notice of death (BI 1663 / DHA 1663) – obtainable from the doctor who certified the death or the undertaker. |

| |

|In the event of unnnatural death: |

| |Police statement completed by investigating officer. |

| |

|NOTES: |

|If the beneficiary lives abroad and is applying for foreign exchange control approval the above requirements must be certified and contain the full name/s, |

|surname, designation and physical address of the Commissioner of Oaths or Notary Public.  These must appear on a stamp or be clearly handwritten and recorded |

|that the documents are “certified a true copy of the original”. |

|Foreign exchange control approval takes a minimum of 8 weeks from date of submission of all the documents required by Standard Bank, in order to process this |

|application. |

|Liberty and the trustees of the Fund reserve the right to call for additional requirements where necessary. FAILURE TO RECEIVE ALL THE REQUIREMENTS WILL DELAY |

|THE CLAIM PROCESS. |

|Please complete all questions - do not make reference to other documents (n/a is not an acceptable answer). |

|Section 1 – Deceased’s details |

| |

|Policy number/s |  |

|Tax reference number |  |  |  |

|Postal address |      |Postal code |      |

|1.2 |Names of insurer, sum assured and date of issue of all insurance held with other companies: |

| |

|Insurer |Policy number |Sum assured |Date |Beneficiary |

|      |      |      |      |      |

|      |      |      |      |      |

|      |      |      |      |      |

|1.3 |Exact cause of death (please do not use natural causes, state the actual cause e.g. cancer). |

| |      |

|1.4 |Has the deceased member ever been insolvent, or are any sequestration proceedings pending or contemplated? | Yes No |

| |If “Yes”, please provide full details: |      |

|1.5 |Was the estate of the deceased member insolvent at the time of death? If “Yes”, please provide full details. | Yes No |

| |      |

|Section 2 - Claimant’s details |

| |

|Surname |  |

| |      |Postal code |      |

| |

|Contact details |

| |

|Telephone numbers: |Work |      |Cell |      |Fax |      |

| |

|Email address |

|2.1 |What was your relationship to the deceased? |      |

| |If spouse, please complete Section 4. | | |

|2.2 |In what capacity do you claim the insurance benefits? | Beneficiary Dependant |

| |

|Section 3 - Declaration of dependency |

| |

|3.1 Spouse/Partner |

| |

|Surname |  |

| |      |Postal code |      |

|Telephone numbers: |Work |      |Cell |      |Fax |      |

| |

|Email |  |  |

|address | | |

|3.1.2 |Was the deceased member previously married? | Yes No |

| |If ‘Yes’, please provide date of divorce. |      | |

| |If ‘Yes’, did the ex-spouse/s receive maintenance? | Yes No |

| |Please provide details on the ex-/estranged spouse: |

| |Ex-/Estranged spouse 1 |Ex-/Estranged spouse 2 |

|Full name |      |      |

|ID number |  |  |

|Maintenance received |*      |*      |

|Dependent on deceased? | Yes No | Yes No |

|Amount |R       |R       |

|Employment status |      |      |

|Remarried | Yes No | Yes No |

|*Amount of maintenance received by previous spouse (excluding maintenance of any children). |

| |

|3.2 List of all children, including major children |

| |

|3.2.1 List all children from the present marriage, previous marriages and/or any legally adopted children or children born out of wedlock. |

| |

|If the child is a student, please attach copies of the following: |

| |

|Proof of registration at educational facility. |

|A note of the approximate cost of fees and details of the field of study. |

|Year of study and expected year of completion. |

|Place of residence (i.e. at home and not responsible for living expenses/at home and responsible for living expenses and other residence costs e.g. campus |

|residence, please specify amounts). |

| |Child 1 |Child 2 |

|Full name |      |      |

|Contact number |      |      |

|Fax number |      |      |

|Email address |  |  |

| |      |Postal code |      |      |Postal code |      |

|Occupation |      |      |

|ID number |  |  |

|If “Yes”, to what extent |      |      |

|(eg. maintenance, | | |

|accommodation, school fees,| | |

|etc.)? | | |

|Guardian’s name |      |      |

|Guardian’s contact no. |      |      |

|Signature of | | |

|guardian/caregiver | | |

| |Child 3 |Child 4 |

|Full name |      |      |

|Contact number |      |      |

|Fax number |      |      |

|Email address |  |  |

| |      |Postal code |      |      |Postal code |      |

|Occupation |      |      |

|ID number |  |  |

|If “Yes”, to what extent |      |      |

|(eg. maintenance, | | |

|accommodation, school fees,| | |

|etc.)? | | |

|Guardian’s name |      |      |

|Guardian’s contact no. |      |      |

|Signature of | | |

|guardian/caregiver | | |

|3.3 Other dependants |

|3.3.1 |List any other person/s that might have been financially dependent on the deceased member at the time of death. Proof of age and proof of extent of |

| |dependency is required. |

|Name |Surname |Contact number |ID number |Relationship to deceased|

| | | | |member |

|      |      |      |      |      |

|      |      |      |      |      |

|      |      |      |      |      |

|      |      |      |      |      |

|3.3.2 |If any of the named dependants are heirs or legatees, please give an estimate of the value of inheritance/legacies. |

|Surname |First names |Approximate value of |

| | |inheritance |

|      |      |R       |

|      |      |R       |

|      |      |R       |

|      |      |R       |

| |

|Section 4 – Death claim declaration |

| |

|I/We, as the claimant/s, claim the benefits of the policy(ies). |

| |

|I/We declare that: |

|The answers and statements are true to the best of my/our knowledge and belief, and |

|that I/we have withheld no material fact. |

| |

|I/We agree that my/our personal details relating to this claim may be shared by the trustees with other claimants who may have an interest in these benefits. |

|I/We understand that this information is disclosed to such claimants as they may have an interest in how the trustees make their recommendations. |

| |

|I/We agree that: |

|Any written statements, affidavits and supporting documents provided in support of this claim will form part of this claim. |

|The supply of this form or of any other forms is not an admission by Liberty that there was any assurance in force on the life of the deceased member or a waiver|

|of any of Liberty’s rights or defence in law. |

|Any benefits payable in respect of this claim will be forfeited if I/we, or anyone acting on my/our behalf or with my/our knowledge, have withheld any material |

|facts or submitted any false information in respect of the claim. |

|Upon payment by Liberty of the benefits claimed by me/us, Liberty will be released from all liability in respect of such benefits. |

|Information on unpaid or unclaimed benefits |

|It is the responsibility of members to ensure that Liberty always has up to date contact information (including that of any potential beneficiary). Where Liberty|

|becomes aware that benefits are payable, we will seek to communicate at the last address provided to us.  If this is unsuccessful, Liberty will take reasonable |

|steps to find those who are entitled to the benefits, which steps may entail the appointment by Liberty of external tracing agents. I/We consent to Liberty |

|appointing an external tracing agent and providing them with the necessary personal information to conduct such tracing. A tracing and management fee as |

|determined at time of tracing may be deducted by Liberty from the benefits payable. Note that in certain circumstances, an additional amount may be payable by |

|Liberty in relation to any late payment. |

|Signed at |      |on |      |

| | | |

| | | |

| | | |

|Signature of claimant | |Signature of witness |

| |

|Section 5 – Financial adviser’s details |

|(Only to be completed if a financial adviser has assisted with the completion of this form.) |

|Commision code |      | |

|Contact numbers: |Work |      |Cell |      |

|Email |      |

| | |

| | |

| | |

|Signature of financial adviser | |

|DECEASED MEMBER INFORMATION FORM (SARS REQUIREMENTS) |

| |

|*The South African Revenue Services (SARS) now requires additional information to be included on the tax certificate. In order to avoid delays in processing the|

|request, or penalties imposed by SARS, please complete the following information in full. Please note all fields required below are mandatory. |

| |

|Deceased member’s details |

| |

|Policy number/s |  |

| |      |Postal code |      |

|Income tax number |

|Contact details |

|Telephone numbers: |Work |      |Cell |      |Fax |      |

| |

|Email address |

|Deceased member’s last postal address details |

| |

|Is this the same as the deceased’s residential address? If “No”, provide last postal address. | Yes No |

|Postal address |      |

| |      |Postal code |      |

| |

|Deceased member’s last business address |

| |

|Is this the same as the deceased’s residential address? If “No”, provide last business address. | Yes No |

|Business address |      |

| |      |Postal code |      |

| |

|Deceased member’s bank account details (excluding credit card) |

|Account holder’s name |      |

|Bank name |      |

|Account number |  |  |  |

|Account holder relationship: | Own | Joint | |

|Signed at |      |on |      |

| | | |

| | | |

| | | |

|Signature of claimant | | |

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